by Bill Hayes
While the letter was addressed to Steve, it wasn’t written to patients such as him, I noticed. It never mentioned, for instance, that the phlebotomist, by reusing needles, could have exposed HIV-positive patients to mutated strains of the virus. It is not just HIV that can be passed on, but an infected person’s entire drug-resistance history. Through reinfection, a patient already low on treatment options could be left with none. Steve put the letter aside and dug up his SmithKline Beecham records, finding he had used the lab eighteen different times.
The investigation of the phlebotomist became a sensational local news story. Reports focused chiefly on the possibility that uninfected patients had been exposed to HIV and hepatitis, which was neither inappropriate nor surprising. The accused had had contact with more than twelve thousand people over a period of many years, so the pool of potential victims was sizable. Even if they weren’t infected, there would be grounds for lawsuits for their emotional distress. But Steve helped me see a perspective never addressed in media accounts—that of a man whose blood could have been the source of infection for another, or even for many others, making him feel like an accessory to crimes he’d been powerless to stop.
“The idea of someone treating my blood so carelessly . . . ,” he said to me, pausing to steady his words. His eyes narrowed. “The possibility of my infecting someone else is horrifying.”
I’ve seen that look in Steve’s eyes one time since, late on a Saturday morning. A few moments earlier, I’d told him to sit down at our kitchen table. “Honey, I’ve gotta tell you something,” I’d said shakily. “It’s really important.”
A lifelong insomniac, I’d been struggling through an awful week of sleeplessness, as Steve knew. I’d rolled out of bed early that morning feeling exhausted yet again. I took a look at my face in the bathroom mirror. My red-rimmed eyes were so bloodshot, I imagined they’d sucked my veins dry, left me iron-poor, a bit anemic. So, I reasoned sleepily, I would be a patient of my own Dr. Feelgood: I would give myself an injection of Steve’s B12.
With the exception of sleeping pills, I’d never once considered taking any of his medications—and there were a couple of tempting ones, including Vicodin, which he used to treat his neuropathy pain. But this was different: a little instant vigor. It’s just a vitamin shot, I told myself as I reached for the vial in our kitchen cabinet.
The B12 injections were a new therapy for Steve. At his doctor’s suggestion, he had been using over-the-counter oral B12 supplements together with a B12 nasal gel, intended mainly as an antidote to drug-induced fatigue. He’d found the nasal gel messy, though, felt no less tired, and wondered, understandably, how much of the vitamin his body was even absorbing. His doctor’s solution: a prescription for full-strength B12, a single one-milliliter injection per week. We picked it up that same day along with a year’s supply of needles, a box of multiple pouches, the syringes within loose like Halloween candy. Steve’s doctor had taught me how to give him the shots, and I’d already done it several times, the last one just the day before. I was a natural, even a tad smug about it. I had no fear of needles, never have, a trait reinforced by the fact that Steve, unflappable in most things, was creeped out by them. He couldn’t even look when I gave him his shot.
In the semidarkness I grabbed one of the syringes, popped off the cap, and jabbed the needle through the glass vial’s gray rubber top. I felt weirdly proud of myself; I’d come up with a brilliant solution for being sleep-deprived. This is going to make me feel so much better! I pulled back the plunger and watched, ebullient, as the syringe filled with the bright red medicine, foaming at the top like a glass of Strawberry Crush. I tapped out the bubbles. Oops, I’d forgotten the rubbing alcohol. I set the syringe on the countertop. Returning from the bathroom, I decided not to give myself a shot in the arm, as I would Steve, but in my butt, so he wouldn’t notice. I wanted to hide it from him.
I pulled down my sweats, swiped a soaked cotton ball on my right cheek, pushed the needle in, pressed the plunger, and just as quickly pulled it out. There: a dewdrop of dark red blood, visual proof that the injection had dived through my white skin. I could almost see fizzy particles of B12 swimming to my heart, my eyes, my limbs, revitalizing me. I smiled at the imagined bursts of energy that would take me through the long day ahead. I slapped on a small bandage, restored the cap to the syringe, turned on the overhead light, and opened the kitchen cabinet.
And that’s when I looked closely at the box of needles. Inside were two open pouches, one with new syringes, one with used. I had reached in blindly, grabbing the first needle I’d felt—a dirty one, I was now sure.
Already, I pictured, a speck of Steve’s blood had entered my circulatory system. I shivered uncontrollably as it raced through my veins, pumped through my heart, seeped into my lungs, swept into my arteries, all the while multiplying, infecting every cell, flooding my body with HIV. What rose from the pit of my stomach and caught in my throat was not bile but blood, thick and sour. It tasted like fear.
I held my breath, as if to choke off all emotion. The moment I exhaled, fear filled the room. Had Steve walked in at that second, rubbing the sleep from his eyes, he’d have been overcome, too. I was having a panic attack; heart thrumming, ears ringing, it took all my strength just to sink into a chair.
Adrenaline was not living up to its reputation. It wasn’t the superhuman jolt I’d have expected—that surge that allows a mother to lift a crumpled car off her injured child or that burst of mental clarity that lays out the world like precise moves on a chessboard. The reality was far from the fantasy, the latter owing heavily to the late-1970s TV show The Incredible Hulk, a guilty pleasure when I was in college. The transformation from scrawny scientist David Banner into the green behemoth was ignited by overpowering emotion. (“Don’t make me angry,” actor Bill Bixby would say, more warning than threat; “you wouldn’t like me when I’m angry.”) Muscles bulged, pants ripped, the shirt shredded, but the Hulk’s transformation was never complete till he smashed through a wall or two.
In my case, my energy imploded. Thoughts raced, getting nowhere. I’d latch on to one and it was irrational. I should suck out the HIV at the injection site, but how do I get my mouth to my hip? I should down a mouthful of Steve’s AIDS drugs, I told myself next. Wouldn’t that stomp out the infection? At some point my mind had ground down to nothing, and I was aware of my heartbeat shaking me awake from myself.
I thought perhaps calm could be restored by my going through the motions of everyday normalcy—showering, eating breakfast, getting dressed. Breathe, I coached myself. Breathe. In the weird fugue state of the guilt-ridden, I watched Steve get up and go through the same rituals I had. But then I couldn’t bear the pretense of ordinariness any longer. I told him I had something to tell him. I asked him to sit down.
Once I’d spilled all, Steve pushed back from the table, stood, and turned toward the kitchen cabinet. He didn’t say a word or, at least, none that I heard. I watched him pull the box of needles from the cabinet, place it on the table, and silently begin counting. He looked up.
“Needles come in bags of ten,” he said, cool and clear. “I opened this new bag yesterday and we used one for my shot. If you’d taken a used needle, I’d be able to find only nine in the bag.”
My mind was fuzz.
Steve was talking to me. I heard “ate.” Ate?
“There are eight in the bag, Bill. See?”
I was starting to understand, coming to ground.
“You used a new needle—you’re fine. Thank God. They’re all here, except the one you took. Where’d you put it?”
Now fear gave way to shame, burning my face. “In the garbage.”
“The garbage?” Steve pulled back, appraising me. “Oh, the trash man’ll love that.”
Steve went silent, clearly expecting me to speak.
“I’m so sorry,” I responded. “I—I’m an idiot. I didn’t sleep. I—”
“Look, I’m glad you’re all right. But . . . do I hav
e to hide these?” He tapped the box.
I didn’t reply. I was still checking Steve’s math in my head. “Eight in the bag? Are you sure that’s right?”
He walked away from the table. “Count ’em yourself.”
I counted. And did so again, later, while Steve went to Walgreens to get a Sharps container. Still, it took me a couple of days to shake the conviction that I’d used a dirty needle, that I might be HIV-infected. Likewise, it took Steve as long to understand my reaction, why my fear lingered. I felt as if I’d nearly been in a car crash, I was finally able to explain to him. And even though I knew I was perfectly safe, I could still hear the screech of tires, still feel the blood rush from the near hit, my pulse racing.
When declaring a person clinically dead, the attending physician or EMT must note in writing that there is no pulse. The carotid artery, just below the curve of the jaw on either side of the neck, is the site most often felt. The pulse is both the last and, in the living, often the first of the vital signs checked. It is the heartbeat by proxy, each throb caused by the powerful contractions that propel oxygenated blood out into the arteries. This outward surge of blood carries such force that the vessels swell to accommodate it; hence a palpable, visible, sometimes even audible pulsation. In all, seven pairs of arterial pulse points dot the human body: at the neck, inner elbows, wrists, and both sides of the groin; in the pit of the knees; behind the ankles; and atop the feet. Typically, arteries are buried deep within the body, but at these points they lie near the skin’s surface and over a bedding of bone. This makes them ideally situated for palpation, examination by touch.
In American Sign Language, the sign for “doctor” is the finger-spelled letter d tapped inside the wrist, which captures in a simple gesture the most fundamental part of a medical exam, the iconic act of taking the pulse. Performed in every culture, this basic diagnostic test is as old as the practice of healing itself. The careful placing of two or three fingers along a tiny stretch of artery used to be considered an art form, a notion largely lost in the mad shuffle of contemporary health care. One needs to page back a good hundred years or so to rediscover a time when this vital sign retained all of its, well, vitalness. I’ve found no more erudite an advocate than Sir William Henry Broadbent, personal physician to Queen Victoria and author of a unique monograph, The Pulse (1890). In its pages Sir William is a spirited defender of what he calls “the educated finger.” In an early passage he subjects the wrist and its pulse point to a curious clinical analysis, as if describing a patient with an odd case history. He is long-winded, but endearingly so: “At first sight it seems strange that the radial artery, which supplies [blood to] merely the structures of a part of the hand—a few small bones with their articulations, a few muscles and tendons, the skin and nerves distributed to it—should afford the varied and far-reaching knowledge we look for in the pulse. The hand is not essential to life, it contains no organ of any importance, and a priori it might have been supposed that the variations in the circulation of the blood in so small a member could have no significance.” There is little about this passage I do not love, from the doctor’s crisp visual dissection to the delicious irony he’s blinded to in his academic fervor: If not for the irrelevant hand, he could not even take the pulse, let alone write about it. But I digress. The distinguished doctor, who’d practiced medicine for more than thirty years by the time his book was published, goes on to state without equivocation that the wrist pulse is a “trustworthy index,” a reliable gauge for the entire circulatory system.
A portrait reproduced on the frontispiece of his memoirs broadens my sense of the man: Seated, he looks the very essence of “bedside manner”—compassionate, patient—as though he’s just asked, “What seems to be the problem?” A stout gentleman in his late sixties, I’d guess, the doctor is dressed in a dark formal suit with a wide satin cravat. A pocket watch is comfortably secreted in his closed palm. Perhaps he can feel the tick of its clockwork against his skin.
In his day the pulse opened a personal dialogue with the body, and a skilled clinician could glean an astonishing array of insights, far beyond a tally of heartbeats per minute. With nothing but his fingertips, Broadbent claimed he could assess the condition and health of the arteries, calculate blood pressure, and discern the emotional well-being or physical ailments of a patient. Even a person with profound sleeplessness was implicated by his pulse. The insomniacal artery, Broadbent wrote, was “full between the beats” and could be “rolled under the finger,” while the pulse waves themselves ended abruptly, as if exhausted from the effort.
An impetus for writing his treatise was Broadbent’s grave concern that physicians’ tactile skills were eroding (or, among young doctors, not fully maturing) as technology was relied upon more and more. Back in the late 1850s, when he’d begun his lengthy career at London’s St. Mary’s Hospital, a newfangled device had started attracting notice, the “sphygmograph,” an ingenious though initially clunky contraption that could create an ink tracing of a patient’s pulse. It worked this way: With the wrist upturned, the forearm was immobilized. A small sensor plate rested atop the pulse point and, in essence, rode the gentle waves; the motion was translated simultaneously onto a strip of paper, forming a steady sequence of squiggles. To the medical community, an instrument that could provide an objective reading of the pulse was an important advance (the modern blood pressure cuff is the sphygmograph’s direct descendant). However, while Broadbent used various models throughout his career, he was never a full convert. In The Pulse he praised the machine’s ability to mimic what a skilled physician could do by hand but emphasized that it was “not an infallible court of appeal.” The device was tricky to operate—it wasn’t like placing a thermometer under a tongue. In fact, Broadbent maintained, many of the “niceties of information” were out of its reach; no machine could ever replace the power of human touch.
In mastering the language of the pulse, Broadbent was linked to a timeless tradition, one transcending cultures and medical philosophies. The physician-priests loyal to the lion-headed Egyptian goddess Sekhmet relied on pulse palpation to reach their diagnoses, as evidenced by tomb inscriptions circa 2000 B.C., and medical papyri from this same era contain repeated reference to the pulse. “The heart speaks out of the vessels of every limb,” one particularly lovely line translates. In the history of medicine, however, the literature of ancient China is unmatched in its extravagant attention to deciphering the body’s rhythmic code.
The Chinese text called Huang Ti Nei Ching Su Wen (The Yellow Emperor’s Classic of Internal Medicine) is one of the world’s earliest and most famous medical guides. Although the work is attributed to the legendary first ancestor of the Chinese nation, historians concede that it is the product of neither a single writer nor single time period but rather a compilation of many teachings over hundreds of years. The oldest portions may date as far back as the fifth century B.C. To me The Yellow Emperor’s Classic is best appreciated not for its physiological accuracy but for its richness of ideas. All of the disciplines of traditional Chinese medicine sprang from its theories.
The entirety of what Broadbent could read at the wrist pulse was just the starting point for what The Yellow Emperor’s Classic describes. By applying varying pressure to different points along that single stretch of artery, an accomplished physician could derive a full accounting of every internal organ as well as a sense of the subtlest qualities of yin and yang, the positive and negative cosmic forces that balance in good health. The physician intuitively correlated into his reading a bewildering string of external factors—the climate, the direction of the wind, colors, odors, tastes, sounds, the natural elements, the positions of constellations, and more—and arrived at a diagnosis. To a Westerner such as myself, this ability seems almost supernatural and far-fetched. I find a stronger resonance in the text’s evocative characterizations. The resting pulse rate of a healthy heart will resemble “a piece of wood floating on water,” for instance, and the throb of a vi
gorous heart “should feel like continuous hammer blows.” The pulses relating to unhealthy conditions are also lyrical. A sickly pulse might reverberate like “the notes of a string instrument” or feel like “fish gliding through waves”—descriptions that nonetheless thrum and flicker with life.
Dr. Broadbent was never so poetic. On the contrary, he encouraged physicians to express no personal style whatsoever when writing about a patient’s pulse, thus eliminating the risk of ambiguity. The rate of pulse beats should be described as either frequent or infrequent, he insisted, with no shades in between. Arteries were large or small, and the “tension” or blood pressure within them high or low. What’s interesting is that this colorless vocabulary obviously did not reflect his wonder at the pulse. “It is impossible to examine a large number of pulses,” he enthused, “without being struck by the extraordinary diversity of frequency, size, character, tension, and force met with.” Of course, Broadbent’s contribution to his field went beyond the crafting of a glossary. During his nearly four decades at St. Mary’s Hospital, he was able to confirm definitively the link between high blood pressure and disease, paying particular note to hypertension in late-stage kidney disease. He was also among the first researchers to elucidate the risks of low blood pressure. In his midsixties William Henry Broadbent was recognized as one of Great Britain’s leading clinicians.
A year after The Pulse was published, he was contacted by officials at Buckingham Palace. The queen’s grandson, Prince George of Wales, had come down with typhoid fever, and the doctor’s expertise was requested. He remained in attendance at the prince’s residence for a month, seeing the twenty-six-year-old through to a complete recovery. Not a week had passed before he was summoned yet again. Now one of George’s brothers had been stricken by influenza, and he died in a matter of days. Word reached Dr. Broadbent that Her Majesty, Queen Victoria herself, wished to see him. Somehow I doubt he was expecting a promotion.
